Awareness : Did You Know? 2015-2016

Did You Know? Weekly Educational Series 7

For the Week of September 28, 2015-General

Physician and Non-Physician Practitioners’ Use if Scribes

Physicians and non-physician practitioners (NPPs) may use the services of a scribe to assist with documentation during a clinical encounter, which may be in an office or facility setting, between the physician/NPP and the patient. A scribe can be an NPP, a nurse, clinical assistant, or other ancillary personnel allowed by the physician/NPP, to document his/her services in the patients’ medical record.

A scribe’s responsibility is to capture an accurate and detailed description (handwritten, electronic, or otherwise) of the patient encounter in a timely manner. Scribes are clerical in nature and are not permitted to make independent decisions or translations while capturing or entering information into the health record beyond what is directed by the physician/NPP.

Clinical staff may be utilized to perform scribe functions, so it is important to clearly define and differentiate their clinical duties from their scribe duties. Even though it’s acceptable for a physician/NPP to use a scribe, current Medicare documentation guidelines must be followed. The physician is ultimately accountable for the documentation and should sign and notate after the scribe’s entry that the documentation accurately reflects the work done by the physician.

Documentation of scribed services should indicate who performed the service and who recorded the service. The scribe’s note should include “written by [name and title of scribe], acting as scribe for Dr./NPP [name of physician/NPP],” and the date and time of entry into the medical record. The physician should legibly co-sign (either hard copy or electronic) and date the entry, stating for example, “the note accurately reflects the work and decisions made by me.”

Documentation made by a scribe should be made upon direction by the physician. This requirement is no different from any other encounter’s documentation requirement. Medicare pays for medically necessary and reasonable services and expects the one delivering the services and creating the record. The scribe should not act independently, and there is no payment for the services of the scribe.